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20201101_UHC PPO with HRA Benefit Summary with Rx Flipbook PDF
20201101_UHC PPO with HRA Benefit Summary with Rx
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INSPIRE COMMUNITIES | November 2020
UHC PPO PLAN WITH HRA UHC PPO PLAN WITH HRA UHC
HRA Secondary
BPCB RX 522 PPO In-Network
Payer Plan
- Deductible: Individual
$5,000
80% after $1,000
$1,000
- Deductible: Family
$10,000
80% after $1,000
$2,000
- Maximum Out-of-Pocket: Individual
$6,500
$4,100
$2,400
- Maximum Out-of-Pocket: Family
$13,000
$8,800
$4,200
$0 Copay
N/A
$0 Copay
$100 Copay
N/A
$100 Copay
$
80% after $1,000
20% AD
- Basic X-Ray
20% AD
80% after $1,000
20% AD
- Complex Imaging
20% AD
80% after $1,000
20% AD
- Preventive Care
No Charge
N/A
No Charge
- Inpatient
20% AD
80% after $1,000
20% AD
- Outpatient Surgery
20% AD
80% after $1,000
20% AD
$50 Copay
N/A
$50 Copay
$250 Copay + 20% AD
80% after $1,000
$250 Copay + 20% AD
$250/$500
N/A
$250/$500
- Generic
$0 Copay
N/A
$0 Copay
- Brand
$35 Copay
N/A
$35 Copay
- Non-Formulary
$100 Copay
N/A
$100 Copay
- Specialty Rx
$250 Copay
N/A
$250 Copay
BENEFITS DESCRIPTION ANNUAL LIMITS
EMPLOYEE PAYS
In Network Only
PHYSICIAN SERVICES - Primary Care Physician Office Visits - Specialist Office Visits - Basic Lab
HOSPITALIZATION
- Urgent Care - Emergency Room (copay waived if admitted) PRESCRIPTIONS - Rx Deductible
This worksheet is for comparison purposes only. Please refer to evidence of coverage for full plan details. Presented by: HUB International - License #0757776
Benefit Summary Select Plus PPO California - Select Plus Balanced - Plan BPCB What is a benefit summary? This is a summary of what the plan does and does not cover. This summary can also help you understand your share of the costs. It’s always best to review your Evidence of Coverage (EOC) and check your coverage before getting any health care services, when possible.
What are the benefits of the Select Plus Plan? Get more protection with a national network and out-of-network coverage. A network is a group of health care providers and facilities that have a contract with UnitedHealthcare. You can receive care and services from anyone in or out of our network, but you save money when you use the network. > There's coverage if you need to go out of the network. Out-of-network means that a provider does not have a contract with us. Choose what's best for you. Just remember out-of-network providers will likely charge you more. > There's no need to choose a primary care provider (PCP) or get referrals to see a specialist. Consider a PCP; they can be helpful in managing your care. > Preventive care is covered 100% in our network.
Are you a member? Easily manage your benefits online at myuhc.com® and on the go with the UnitedHealthcare Health4Me® mobile app. For questions, call the member phone number on your health plan ID card.
Not enrolled yet? Search for network doctors or hospitals at welcometouhc.com or call 1866-873-3903, TTY 711, 8 a.m. to 8 p.m. local time, Monday through Friday.
Benefits At-A-Glance What you may pay for network care This chart is a simple summary of the costs you may have to pay when you receive care in the network. It doesn’t include all of the deductibles and co-payments you may have to pay. You can find more benefit details beginning on page 2. Co-payment (Your cost for an office visit) You have no co-payment.
Individual Deductible
Co-insurance
(Your cost before the plan starts to pay) (Your cost share after the deductible) $5,000
20%
This Benefit Summary is to highlight your Benefits. Don't use this document to understand your exact coverage for certain conditions. If this Benefit Summary conflicts with the Evidence of Coverage (EOC), Schedule of Benefits, Riders, and/or Amendments, those documents are correct. Review your EOC for an exact description of the services and supplies that are and are not covered, those which are excluded or limited, and other terms and conditions of coverage. UnitedHealthcare Benefits Plan of California
Page 1 of 14
Your Costs In addition to your premium (monthly) payments paid by you or your employer, you are responsible for paying these costs. Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
Annual Deductible What is an annual deductible? The annual deductible is the amount you pay for Covered Health Care Services per year before you are eligible to receive Benefits. It does not include any amount that exceeds Allowed Amounts. The deductible may not apply to all Covered Health Care Services. You may have more than one type of deductible. > Your co-pays don't count towards meeting the deductible unless otherwise described within the specific covered health care service. > All individual deductible amounts will count towards meeting the family deductible, but an individual will not have to pay more than the individual deductible amount. Medical Deductible - Individual
$5,000 per year
$10,000 per year
Medical Deductible - Family
$10,000 per year
$20,000 per year
Out-of-Pocket Limit What is an out-of-pocket limit? The Out-of-Pocket Limit is the maximum you pay per year. Once you reach the Out-of-Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. > All individual out-of-pocket limit amounts will count towards meeting the family out-of-pocket limit, but an individual will not have to pay more than the individual out-of-pocket limit amount. > Your co-pays, co-insurance and deductibles (including pharmacy) count towards meeting the out-of-pocket limit. Out-of-Pocket Limit - Individual
$6,500 per year
$13,000 per year
Out-of-Pocket Limit - Family
$13,000 per year
$26,000 per year
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Your Costs What is co-insurance? Co-insurance is the amount you pay each time you receive certain Covered Health Care Services calculated as a percentage of the Allowed Amount (for example, 20%). You pay co-insurance plus any deductibles you owe. Coinsurance is not the same as a co-payment (or co-pay). What is a co-payment? A Co-payment is the amount you pay each time you receive certain Covered Health Care Services calculated as a set dollar amount (for example, $50). You are responsible for paying the lesser of the applicable Co-payment or the Allowed Amount. Please see the specific Covered Health Care Service to see if a co-payment applies and how much you have to pay. What is Prior Authorization? Prior Authorization is getting approval before you receive certain Covered Health Care Services. Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization. However there are some Benefits that you are responsible for obtaining authorization before you receive the services. Please see the specific Covered Health Care Service to find services that require you to obtain prior authorization. Want more information? Find additional definitions in the glossary at justplainclear.com.
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Your Costs Following is a list of services that your plan covers in alphabetical order. In addition to your premium (monthly) payments paid by you or your employer, you are responsible for paying these costs. Covered Health Care Services Ambulance Services Emergency Ambulance:
Non-Emergency Ambulance:
Cellular and Gene Therapy For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider.
Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
20% co-insurance, after the medical deductible has been met.
20% co-insurance, after the network medical deductible has been met.
20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met.
Prior Authorization is required for Non-Emergency Ambulance.
Prior Authorization is required for Non-Emergency Ambulance.
The amount you pay is based on where the covered health care service is provided.
Out-of-Network Benefits are not available.
Prior Authorization is required. Clinical Trials The amount you pay is based on where the covered health care service is provided. Prior Authorization is required. Congenital Heart Disease (CHD) Surgeries 20% co-insurance, after the medical deductible has been met. Dental Anesthesia Limited to Covered Persons who are one of the following: a child under seven years of age; a person who is developmentally disabled, regardless of age; a person whose health is compromised and for whom general anesthesia is required, regardless of age.
20% co-insurance, after the medical deductible has been met.
Dental Services and Oral Surgery - Accident Only 20% co-insurance, after the medical deductible has been met.
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Prior Authorization is required. 50% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met.
20% co-insurance, after the network medical deductible has been met.
Your Costs Covered Health Care Services Diabetes Services Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care: For Self-Management and Training, cost sharing will not exceed the costs for Physician office visit.
Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
The amount you pay is based on where the covered health care service is provided.
Prior Authorization is required for DME that costs more than $1,000. Diabetes Treatment Coverage for diabetes equipment and supplies, prescription items and diabetes self-management training programs when provided by or under the direction of a Physician.
The amount you pay is based on where the covered health care service is provided. See prescription drug benefit and Durable Medical Equipment (DME), Orthotics and Supplies for coverage of diabetes equipment and supplies.
Durable Medical Equipment (DME), Orthotics and Supplies 20% co-insurance, after the medical deductible has been met. Emergency Health Care Services - Outpatient After you pay the $250 co-pay per visit; you pay 20% co-insurance, after the medical deductible has been met.
Out-of-Network Benefits are not available.
After you pay the $250 co-pay per visit; you pay 20% co-insurance, after the network medical deductible has been met.
Gender Dysphoria The amount you pay is based on where the covered health care service is provided.
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Your Costs Covered Health Care Services Habilitative Services Inpatient: Outpatient: Limited to: 24 visits of Manipulative Treatments.
Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
The amount you pay is based on where the covered health care service is provided. 20% co-insurance, after the medical deductible has been met.
For the above outpatient therapies: Limits for Out-of-Network Benefits will be the same as, and combined with, those stated under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment. Visit limits are not applied to occupational therapy, physical therapy or speech therapy for the Medically Necessary treatment of a health condition, including pervasive developmental disorder or Autism Spectrum Disorders.
Out-of-Network Benefits are not available for physical therapy, occupational therapy, and Manipulative Treatments. 50% co-insurance, after the medical deductible has been met for all other therapies.
Prior Authorization is required for certain Inpatient services. Hearing Aids Limited to $2,500 every year. Benefits are further limited to a single purchase per hearing impaired ear every three years. Repair and/or replacement of a hearing aid would apply to this limit in the same manner as a purchase. Home Health Care Limited to 100 visits per year. One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of intravenous infusion. To receive Network Benefits for the administration of intravenous infusion, you must receive services from a provider we identify.
20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met.
20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. For Out-of-Network Benefits, Allowed Amounts are limited to $150 per visit.
Prior Authorization is required.
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Your Costs Covered Health Care Services
Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met.
Hospice Care
Prior Authorization is required for Inpatient Stay. Hospital - Inpatient Stay 20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. Prior Authorization is required.
Lab, X-Ray and Diagnostic - Outpatient Lab Testing - Outpatient: 20% co-insurance, after the medical deductible has been met.
Out-of-Network Benefits are not available.
X-Ray and Other Diagnostic Testing Outpatient:
50% co-insurance, after the medical deductible has been met.
20% co-insurance, after the medical deductible has been met.
Prior Authorization is required for Genetic Testing, sleep studies, stress echocardiography and transthoracic echocardiogram services. Major Diagnostic and Imaging - Outpatient 20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. Prior Authorization is required.
Mastectomy Services The amount you pay is based on where the covered health care service is provided. Mental Health Care and Substance - Related and Addictive Disorders Services Inpatient: 20% co-insurance, after the medical 50% co-insurance, after the medical deductible has been met. deductible has been met. Outpatient:
You pay nothing. A deductible does not apply.
50% co-insurance, after the medical deductible has been met.
Partial Hospitalization/Intensive Outpatient Treatment:
20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. Prior Authorization is required.
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Your Costs Covered Health Care Services Obesity - Weight Loss Surgery For Network Benefits, obesity-weight loss surgery must be received from a Designated Provider.
Your cost if you use Network Benefits The amount you pay is based on where the covered health care service is provided.
Your cost if you use Out-of-Network Benefits Out-of-Network Benefits are not available.
Prior Authorization is required. Off-Label Drug Use and Experimental or Investigational Services The amount you pay is based on where the covered health care service is provided. Osteoporosis Services The amount you pay is based on where the covered health care service is provided. Ostomy Supplies 20% co-insurance, after the medical deductible has been met. Pharmaceutical Products - Outpatient This includes medications given at a 20% co-insurance, after the medical doctor’s office, or in a Covered deductible has been met. Person’s home.
Out-of-Network Benefits are not available. 50% co-insurance, after the medical deductible has been met.
Phenylketonuria (PKU) Treatment 20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. Prior Authorization is required.
Physician Fees for Surgical and Medical Services 20% co-insurance, after the medical deductible has been met. Physician’s Office Services - Sickness and Injury You pay nothing for a primary care physician office visit. A deductible does not apply.
50% co-insurance, after the medical deductible has been met. 50% co-insurance, after the medical deductible has been met.
$100 co-pay per visit for a specialist office visit. A deductible does not apply. Additional co-pays, deductible, or co-insurance may apply when you receive other services at your physician's office. For example, surgery and lab work.
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Your Costs Covered Health Care Services Pregnancy - Maternity Services We pay for Covered Health Care Services incurred if you participate in the California Prenatal Screening Program, a statewide prenatal testing program administered by the State Department of Health Services. There is no cost share for this Benefit. All maternity items and services that are recommended preventive care and are required to be covered under the Affordable Care act, will be provided without cost share. Please refer to Preventive Care Services. Prenatal care office visits received from a Network provider are covered without cost sharing during the entire course of the Covered Person's pregnancy.
Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
The amount you pay is based on where the covered health care service is provided except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.
Prior Authorization is required if the stay in the hospital is longer than 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery. Prescription Drug Benefits Prescription drug benefits are shown in the Prescription Drug benefit summary. Preventive Care Services Physician Office and other Preventive Services.
You pay nothing. A deductible does not apply.
Out-of-Network Benefits are not available.
Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age, gender and other health factors. UnitedHealthcare also covers other routine services that may require a co-pay, co-insurance or deductible. Prosthetic Devices 20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. Prior Authorization is required for Prosthetic Devices that costs more than $1,000.
Reconstructive Procedures The amount you pay is based on where the covered health care service is provided. Prior Authorization is required.
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Your Costs Covered Health Care Services
Your cost if you use Network Benefits
Your cost if you use Out-of-Network Benefits
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment Limited to: 20% co-insurance, after the medical Out-of-Network Benefits are not deductible has been met. available for physical therapy, 24 visits of Manipulative Treatments. occupational therapy, and Visit limits are not applied to Manipulative Treatments. occupational therapy, physical therapy 50% co-insurance, after the medical or speech therapy for the Medically deductible has been met for all other Necessary treatment of a health therapies. condition, including pervasive developmental disorder or Autism Spectrum Disorders. Scopic Procedures - Outpatient Diagnostic and Therapeutic Diagnostic/therapeutic scopic 20% co-insurance, after the medical procedures include, but are not limited deductible has been met. to colonoscopy, sigmoidoscopy and endoscopy. Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Limited to 100 days per year for Skilled 20% co-insurance, after the medical Nursing Facility. deductible has been met.
50% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. Prior Authorization is required.
Surgery - Outpatient 20% co-insurance, after the medical deductible has been met.
50% co-insurance, after the medical deductible has been met. For Out-of-Network Benefits, Allowed Amount for Facility Fees are limited to $760 per date of service. Prior Authorization is required for certain services.
Telehealth Services The amount you pay is based on where the covered health care service is provided. Temporomandibular Joint (TMJ) Services The amount you pay is based on where the covered health care service is provided. Prior Authorization is required for Inpatient Stay.
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Your Costs Covered Health Care Services
Your cost if you use Network Benefits
Therapeutic Treatments - Outpatient Therapeutic treatments include, but are 20% co-insurance, after the medical not limited to dialysis, intravenous deductible has been met. chemotherapy, intravenous infusion, medical education services and radiation oncology.
Your cost if you use Out-of-Network Benefits 50% co-insurance, after the medical deductible has been met.
Prior Authorization is required for certain services. Transplantation Services Network Benefits must be received from a Designated Provider.
The amount you pay is based on where the covered health care service is provided.
Out-of-Network Benefits are not available.
Prior Authorization is required. Urgent Care Center Services $50 co-pay per visit. A deductible does not apply.
50% co-insurance, after the medical deductible has been met.
Additional co-pays, deductible, or co-insurance may apply when you receive other services at the urgent care facility. For example, surgery and lab work. Urinary Catheters
Virtual Visits Network Benefits are available only when services are delivered through a Designated Virtual Visit Network Provider. You can find a Designated Virtual Visit Network Provider by contacting us at myuhc.com® or the telephone number on your ID card. Access to Virtual Visits and prescription services may not be available in all states or for all groups.
20% co-insurance, after the medical deductible has been met.
Out-of-Network Benefits are not available.
You pay nothing. A deductible does not apply.
Out-of-Network Benefits are not available.
Vision Exams Find a listing of Spectera Eyecare Network Vision Care Providers at myuhcvision.com. Limited to 1 exam every 24 months.
You pay nothing. A deductible does not apply.
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Out-of-Network Benefits are not available.
Services your plan generally does NOT cover. It is recommended that you review your EOC, Amendments and Riders for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
• • • • • • • • • •
Acupuncture Cosmetic Surgery Dental Care (Adult/Child) Glasses Infertility Treatment Long-Term Care Non-emergency care when traveling outside the U.S. Private-Duty Nursing Routine Foot Care Weight Loss Programs
For Internal Use only: CAMAD02BPCB19 Item# Rev. Date 999-3182
1119_rev03
B14-063/Sep/Emb/47681/2018
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UnitedHealthcare Benefits Plan of California does not treat members differently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. United HealthCare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 We provide free services to help you communicate with us. Such as, letters in others languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
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Benefit Summary Outpatient Prescription Drug Products California Plan 522 Standard Drugs: 0/35/100/250 Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2, Tier 3 or Tier 4. Find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging into your account on myuhc.com® or calling the Customer Care number on your ID card.
Annual Drug Deductible - Network and Out-of-Network Individual Deductible Family Deductible
$250 (Deductible does not apply to Tier 1) $500 (Deductible does not apply to Tier 1)
Out-of-Pocket Drug Limit - Network Individual Out-of-Pocket Limit Family Out-of-Pocket Limit
See the Medical Benefit Summary for the total Individual Out-of-Pocket Limit that applies. See the Medical Benefit Summary for the total Family Out-of-Pocket Limit that applies.
Out-of-Pocket Limit does not apply to Out-of-Network Charges.
This summary of Benefits is intended only to highlight your Benefits for Outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all of your Outpatient Prescription Drug expenses. Please refer to your Outpatient Prescription Drug SBN and Evidence of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Outpatient Prescription Drug SBN or the Evidence of Coverage, the Outpatient Prescription Drug SBN and Evidence of Coverage shall prevail. UnitedHealthcare Benefits Plan of California Page 1 of 6
Tier Level
Up to 31-day supply
Up to 90-day supply
Retail Network Pharmacy or Preferred Specialty Network Pharmacy
Retail Out-of-Network Pharmacy
*Mail Order Network Pharmacy or Preferred 90 Day Retail Network Pharmacy**
Tier 1 Prescription Drug Products
No Co-payment
No Co-payment
No Co-payment
Tier 2 Prescription Drug Products
$35
$35
$87.50
Tier 3 Prescription Drug Products
$100
$100
$250
Tier 4 Prescription Drug Products
$250
$250
$625
Benefit Plan Co-payment/Co-insurance - The amount you pay for Prescription Drug Products. * Only certain Prescription Drug Products are available through mail order; please visit myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information. If you choose to opt out of Mail Order Network Pharmacy but do not inform us, you will be subject to the Out-of-Network Benefit for that Prescription Drug Product after the allowed number of fills at the Retail Network Pharmacy. **You will be charged a retail Co-payment and/or Co-insurance for 31 days or 2 times for 60 days based on the number of days supply dispensed for any Prescription Order or Refills sent to the mail order pharmacy. To maximize your Benefit, ask your Physician to write your Prescription Order or Refill for a 90-day supply, with refills when appropriate, rather than a 30-day supply with three refills.
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Other Important Information about your Outpatient Prescription Drug Benefits The amounts you are required to pay is based on the Prescription Drug Charge for Network Benefits and the Out-of-Network Reimbursement Rate for out-of-Network Benefits. For out-of-Network Benefits, you are responsible for the difference between the Out-of-Network Reimbursement Rate and the out-of-Network Pharmacy’s Usual and Customary Charge. We will not reimburse you for any non-covered drug product. For Prescription Drug Products at a retail Network Pharmacy, you are responsible for paying the lower of the applicable Copayment and/or Co-insurance, the Network Pharmacy's retail price for the Prescription Drug Product. For Prescription Drug Products from a mail order Network Pharmacy, you are responsible for paying the lower of the applicable Co-payment and/or Coinsurance or a Network Pharmacy's retail price for the Prescription Drug Product. See the Co-payments and/or Co-insurance in the Benefit Information table for amounts. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. Specialty Prescription Drug Products supply limits are as written by the provider, up to a consecutive 31-day supply of the Specialty Prescription Drug Product, unless adjusted based on the drug manufacturer's packaging size, or based on supply limits. Supply limits apply to Specialty Prescription Drug Products obtained at a Preferred Specialty Network Pharmacy, a Non-Preferred Specialty Network Pharmacy, an out-of-Network Pharmacy, a mail order Network Pharmacy or a Designated Pharmacy. Certain Prescription Drug Products for which Benefits are described under the Prescription Drug Rider are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at myuhc.com® or the telephone number on your ID card. Before certain Prescription Drug Products are dispensed to you, your Physician, your pharmacist or you are required to obtain prior authorization from us or our designee to determine whether the Prescription Drug Product is in accordance with our approved guidelines and it meets the definition of a Covered Health Care Service and is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. You may be required to fill the first Prescription Drug Product order and obtain 2 refills through a retail pharmacy before using a mail order Network Pharmacy. Certain Preventive Care Medications may be covered. You can get more information by contacting us at myuhc.com® or the telephone number on your ID card. Benefits are provided for certain Prescription Drug Products dispensed by a mail order Network Pharmacy or Preferred 90 Day Retail Network Pharmacy. The Outpatient Prescription Drug Schedule of Benefits will tell you how mail order Network Pharmacy and Preferred 90 Day Retail Network Pharmacy supply limits apply. Please contact us at myuhc.com® or the telephone number on your ID card to find out if Benefits are provided for your Prescription Drug Product and for information on how to obtain your Prescription Drug Product through a mail order Network Pharmacy or Preferred 90 Day Retail Network Pharmacy. Product forms included herein are subject to approval by regulators. If the product forms offered herein are subsequently modified by regulators we will immediately advise you of the change in plan design and if necessary retroactively adjust premium in subsequent billings, in accordance with applicable law.
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PHARMACY EXCLUSIONS The following exclusions and limitations apply. In addition see your Pharmacy SBN and Evidence of Coverage for additional exclusions and limitations that may apply.
Pharmacy Exclusions and Limitations • A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutically Equivalent to another covered Prescription Drug Product unless Medically Necessary. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. • A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version of and Therapeutically Equivalent to another covered Prescription Drug Product unless Medically Necessary. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. • Certain Prescription Drug Products for which there are Therapeutically Equivalent alternatives available, unless otherwise required by law or approved by us. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. • Experimental or Investigational medications; medications used for experimental treatments for specific diseases and/or dosage regimens are not covered, unless required by an external, independent review panel pursuant to California Health and Safety Code Section 1370.4 as seen in the Evidence of Coverage. • Any product dispensed for the purpose of appetite suppression or weight loss. • Medications used for cosmetic purposes. • Prescription Drug Products when prescribed to treat infertility. • Certain Prescription Drug Products for tobacco cessation. • Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless we have designated the over-the-counter medication as eligible for coverage as if it were a Prescription Drug Product and it is obtained with a Prescription Order or Refill from a Physician. Prescription Drug Products that are available in over-the-counter form or made up of components that are available in over-the-counter form or equivalent. Certain Prescription Drug Products that we have determined are Therapeutically Equivalent to an over-the-counter drug or supplement. Such determinations may be made up to six times during a calendar year. We may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. This exclusion does not apply to prescribed overthe-counter FDA-approved contraceptives or over-the-counter medications that have an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF) when prescribed by a provider for which Benefits are available, without cost sharing, as described under Section 5 of the Evidence of Coverage. • Any product prescription or non-prescription for which the primary use is a source of dietary or nutritional products, nutritional supplements, or dietary management of disease, including vitamins (except prenatal) minerals and fluoride supplements, health or beauty aids, herbal supplements and/or alternative medicines and prescription medical food products even when used for the treatment of a health condition, except as described under Phenylkeonuria (PKU) Treatment in the Evidence of Coverage. Phenylketonuria (PKU) testing and treatment is covered under your medical benefit including those formulas and special food products that are a part of a diet prescribed by a Network Physician provided that the diet is Medically Necessary. This exclusion does not apply to authorized Medically Necessary services to treat Severe Mental Illness (SMI) or Serious Emotional Disturbances of a Child (SED).
CAMPMAA52219 Item# Rev. Date 999-1997 1119_rev02
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UnitedHealthcare Benefits Plan of California does not treat members differently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. United HealthCare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 We provide free services to help you communicate with us. Such as, letters in others languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m.
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